Probiotics

Nancy Toedter Williams

Am J Health Syst Pharm. 2010;67(6):449-458.

Drug Interactions

Since probiotics contain live microorganisms, concurrent administration of antibiotics could kill a large number of the organisms, reducing the efficacy of the Lactobacillus and Bifidobacterium species. Patients should be instructed to separate administration of antibiotics from these bacteria-derived probiotics by at least two hours.^[58,72] Similarly, S. boulardii might interact with antifungals, reducing the efficacy of this probiotic.^[73] According to the manufacturer, Florastor, which contains S. boulardii, should not be taken with any oral systemic antifungal products.^[74] Probiotics should also be used cautiously in patients taking immunosuppressants, such as cyclosporine, tacrolimus, azathioprine, and chemotherapeutic agents, since probiotics could cause an infection or pathogenic colonization in immunocompromised patients.^[58,72,73]

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Cite this: Probiotics - Medscape - Mar 15, 2010.

Table 1. Microorganisms Used as Probiotics ^[2,5–7]
Bacteria
Lactobacillus species
L. acidophilus
L. bulgaricus
L. casei
L. crispatus
L. fermentum
L. gasseri
L. johnsonii
L. lactis
L. plantarum
L. reuteri
L. rhamnosus GG
Bifidobacterium species
B. adolescentis
B. animalis
B. bifidum
B. breve
B. infantis
B. lactis
B. longum
Bacillus cereus
Enterococcus faecalisa
Enterococcus faeciuma
Escherichia coli Nissle
Streptococcus thermophilus
Yeast
Saccharomyces boulardii

^a Concerns exist about using enterococci as probiotics because of possible pathogenicity and vancomycin resistance.

Table 2. Probiotic Species and Dosing ^a
Indication and Probiotic	Recommended Dosage Regimen
Acute infectious diarrhea in infants and children
Lactobacillus rhamnosus GG (LGG)	At least 10¹⁰ CFU in 250 mL of oral rehydration solution;^[25] 10¹⁰–10¹¹ CFU twice daily for 2–5 days^[26]
Lactobacillus reuteri	10¹⁰–10¹¹ CFU daily up to 5 days^[26]
Antibiotic-associated diarrhea
Saccharomyces boulardii	4 × 10⁹–2 × 10¹⁰ CFU daily for 1–4 wk^[30]
LGG	6 × 10⁹–4 × 10¹⁰ CFU daily for 1–2 wk^[30]
Lactobacillus acidophilus and Lactobacillus bulgaricus	2 × 10⁹ CFU daily for 5–10 days^[30]
L. acidophilus and Bifidobacterium longum	5 × 10⁹ CFU daily for 7 days^[30]
L. acidophilus and Bifidobacterium lactis	1 × 10¹¹ CFU daily for 21 days^[30]
Clostridium difficile infection
S. boulardii	2 × 10¹⁰ CFU (1 g) daily for 4 wk plus vancomycin and/or metronidazole^[30]
Travelers' diarrhea
LGG	2 × 10⁹ bacteria daily starting 2 days before departure and continued throughout trip^[34]
S. boulardii	5 × 10⁹–2 × 10¹⁰ CFU daily starting 5 days before departure and continued throughout trip^[36]
Irritable bowel syndrome
VSL#3^b	9 × 10¹¹ CFU daily for 8 wk^[38]
Bifidobacterium infantis 35624	10⁶–10¹⁰ CFU daily for 4 wk^[38]
LGG and other organisms	8–9 × 10⁹ CFU daily for 6 mo^[24,38]
Ulcerative colitis (UC)
Escherichia coli Nissle 1917	Active UC: 5 × 10¹⁰ bacteria twice daily until remission (maximum of 12 wk), followed by 5 × 10¹⁰ bacteria daily for a maximum of 12 mo39; inactive UC: 5 × 10¹⁰ bacteria daily (study duration was 12 wk)^[40]
S. boulardii	Active UC: 250 mg 3 times daily for 4 wk plus mesalamine^[42]
VSL#3^b	Active UC: 1.8 × 10¹² bacteria (two 3-g sachets) twice daily for 6 wk plus conventional therapy^[43]
Crohn's disease
S. boulardii	Maintenance therapy: 1 g daily for 6 mo plus mesalamine^[44]
Pouchitis
VSL#3^b	Maintenance therapy: 1.8 × 10¹² bacteria daily, given as 3-g sachets twice daily (study duration was 9 mo)46; maintenance therapy: 1.8 × 10¹² bacteria daily, given as two 3-g sachets once daily (study duration was 12 mo)^[48]
Atopic disease prevention
LGG	10¹⁰ CFU daily for 2–4 wk before expected delivery in pregnant women, followed by infant administration for 6 mo^[50]
Vulvovaginal candidiasis
LGG	10⁹ bacteria per suppository inserted twice daily for 7 days^[54]
L. rhamnosus GR-1 and Lactobacillus fermentum RC-14	At least 10⁹ bacteria suspended in skim milk given orally twice daily for 14 days^[55]

^a CFU = colony-forming units.
^b VSL#3 is a mixture of eight probiotic organisms (Lactobacillus casei, L. plantarum, L. acidophilus, L. bulgaricus, B. longum, Bifidobacterium breve, B. infantis, and Streptococcus thermophilus).

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